Spinal tuberculosis in adults. A study of 103 cases in a developed country, 1980-1994.

Spinal tuberculosis (TB) accounts for about 2% of all cases of TB. New methods of diagnosis such as magnetic resonance imaging (MRI) or percutaneous needle biopsy have emerged. Two distinct patterns of spinal TB can be identified, the classic form, called spondylodiscitis (SPD) in this article, and an increasingly common atypical form characterized by spondylitis without disk involvement (SPwD). We conducted a retrospective study of patients with spinal TB managed in the area of Paris, France, between 1980 and 1994 with the goal of defining the characteristics of spinal TB and comparing SPD to SPwD. The 103 consecutive patients included in our study had TB confirmed by bacteriologic and/or histologic studies of specimens from spinal or paraspinal lesions (93 patients) or from extraspinal skeletal lesions (10 patients). Sixty-eight percent of patients were foreign-born subjects from developing countries. None of our patients was HIV-positive. SPD accounted for 48% of cases and SPwD for 52%. Patients with SPwD were younger and more likely to be foreign-born and to have multiple skeletal TB lesions. Neurologic manifestations were observed in 50% of patients, with no differences between the SPD and SPwD groups. Of the 44 patients investigated by MRI, 6 had normal plain radiographs; MRI was consistently positive and demonstrated epidural involvement in 77% of cases. Bacteriologic and histologic yields were similar for surgical biopsy (n = 16) and for percutaneous needle aspiration and/or biopsy (n = 77). Cultures for Mycobacterium tuberculosis were positive in 83% of patients, and no strains were resistant to rifampin. Median duration of antituberculous chemotherapy was 14 months. Surgical treatment was performed in 24% of patients. There were 2 TB-related deaths. Our data suggest that SPwD may now be the most common pattern of spinal TB in foreign-born subjects in industrialized countries. The reasons for this remain to be elucidated.

Hemodialysis-associated amyloidosis and beta-2 microglobulin. Clinical and immunohistochemical study.

The beta-2 microglobulin type of amyloidosis was identified in articular and para-articular tissues of 14 patients with non-amyloid nephropathies undergoing long-term hemodialysis. Ten patients had carpal tunnel syndrome, 13 had juxta-articular radiolucent cysts (complicated by spontaneous fractures of the femoral neck in three), and six had destructive arthropathies of the large joints of the limbs. Massive amyloid deposits were found in the synovium, capsule, ligaments, articular cartilage, and/or bone. They were characterized by Congo red-induced green birefringence that was sensitive to potassium permanganate treatment. They reacted with anti-beta-2 microglobulin antiserum, whereas they did not react with antibodies directed against AA protein, prealbumin, or immunoglobulins. These data suggest that the potentially disabling arthropathy of hemodialysis is due to amyloid lesions. The persistently elevated plasma beta-2 microglobulin levels may play a role in the pathogenesis of this recently recognized complication, and if so, this complication should be preventable.

Lymphocyte tubular structures in rheumatoid arthritis.

Two types of lymphocyte tubular structures were studied by electron microscopy in 80 patients with classic or definite rheumatoid arthritis (RA). Fifteen patients with unequivocal systemic lupus erythematosus (SLE) and 10 healthy persons were studied as controls. Lymphocyte tubulo-reticular structures were found in 13 of the 80 patients with RA and in 10 of the 15 patients with SLE. No tubuloreticular structures were found in any of the healthy subjects. In the RA patients antinuclear antibodies, LE cell phenomenon, and chlorambucil treatment were associated significantly with these inclusions but disease activity was not related to their presence. In cases in which tubuloreticular structures were present the number of cells containing inclusions was on average much lower in patients with RA than in those with SLE. Lymphocyte tubular parallel arrays were found in all the patients with RA and SLE and in all the healthy persons. In all three groups the average number of cells containing parallel tubular arrays was similar.

Light and electron microscopy study of capillaries in normal and inflammatory human synovial membrane.

Synovium aspirated from the knee joint by trochar was studied by light and electron microscopy in 40 cases of inflammatory arthritis and in 10 controls. The morphology of synovial capillaries, extravascular plasma diffusion, interendothelial vascular gaps, extracapillary blood cell migration, vascular congestion, endothelial hyperplasia, and obliteration of the capillary lumen by endothelial cells were compared in normal and inflammatory synovia. Inflammatory synovitis was characterised by the number and diversity of blood cells migrating through the interendothelial pathway out of the capillary lumen. Polymorphonuclear leucocytes were the blood cells most often seen at interendothelial junctions. No other capillary changes that might be related to synovial inflammation were found.

Vascular endothelial cell injury in progressive systemic sclerosis and other connective tissue diseases.

The growth inhibition of in vitro vascular endothelial cell cultures by sera from patients with connective tissue diseases was studied. Seven out of 30 sera from patients with progressive systemic sclerosis (PSS) exhibited a cytotoxic effect. The cytotoxic serum factor(s) was not specific to patients with PSS, it was also demonstrated in sera from patients with other connective tissue diseases with vascular symptoms (11 out of 27 sera from patients with a mixed connective tissue disease, MCTD; 5 out of 34 sera from patients with a systemic lupus erythematosus, SLE). The cytotoxic effect was not specific for vascular endothelial cells, it was also found on fibroblast cells cultures. Inhibitor(s) of cell growth in vitro was independent of antinuclear and anticytoplasmic antibodies and appeared as a common feature of all connective tissue diseases with vascular symptoms.

Comparison of effects of D. Penicillamine and dexamethasone on the articular and non articular lesions in immune connective tissue disease induced in rabbits.

The effect of D. Penicillamine (DP) at the dose of 50 mg/kg/day, on an immune induced connective tissue disease in rabbit, is compared to that of dexamethasone (Dexa) at the doses of 0.15 and 0.075 mg/kg/day. This model includes polyarthritis and lesions of connective tissue of liver, kidneys and lungs. The result of immunization is initially a non-specific macrophage infiltration and secondarily a specific lymphocyte and plasma-cell infiltration. In short treatment, high dose of Dexa inhibits the non-specific and specific responses while DP modifies only non specific response. In long treatment, Dexa at low dose and DP inhibit the two responses. Data suggest that, in vivo, macrophages is the target cell of DP.

[Autoimmunity to collagen, experimental arthritis and rheumatic disease]. / Auto-immunité anti-collagène, arthrite expérimentale et maladie rhumatoïde.

Auto-immunity to type II collagen is now recognised as a good experimental model of arthritis. The possibility of a post-immunization treatment with collagen to suppress or abrogate the arthritic response is particularly interesting in the therapeutical trends suggested by such a possibility. In human pathology, if the pathogenic role of anti-native collagen type II auto-antibodies is well demonstrated in relapsing polychondritis, in the contrary, this hypothesis does not seem relevant to rheumatoid arthritis. In this disease, the role of the auto-immunity to native collagen appears secondary.

[Epidemiological aspects of osteoarticular tuberculosis in adults. Retrospective study of 206 cases diagnosed in the Paris area from 1980 to 1994]. / Aspects épidémiologiques de la tuberculose ostéo-articulaire de l'adulte. Etude rétrospective de 206 cas diagnostiqués en région parisienne de 1980 à 1994.

OBJECTIVES: The aim of this study was to determine the epidemiologic features of bone and joint tuberculosis in the Paris area from 1980 to 1994. METHODS: This retrospective study included 206 cases of confirmed bone and joint tuberculosis (in situ specimen) diagnosed from 1980 to 1994 in 7 hospital units (mainly rheumatology clinics) in Paris and suburban areas. RESULTS: The number of cases increased by a mean 12 per year from 1980 to 1989 then by 17 cases per year from 1990 to 1994. In both 1993 and 1994 there were 21 cases per year. The percentage of immigrant patients was 53% from 1980 to 1989 then reached 74% for 1990-1994, predominantly in subjects from black Africa. Only one patient in the series had human immunodeficiency virus (HIV) infection. A favoring factor was found in 23% of the immigrant and in 45% of the native French patients. Mean age was 37 years in immigrants and 58 years in French patients. Compared with French patients, immigrants had a higher rate of multifocal bone and joint tuberculosis, peripheral osteitis and spondylitus. CONCLUSION: Our findings suggest that the incidence of bone and joint tuberculosis has increased in Paris in 1993 and 1994. Two populations are especially susceptible: the elderly and/or immunodepressed French population and immigrants coming from endemic zones. The role or HIV infection was minimal in this predominantly rheumatology series.

[Bone metastases in epidural invasion of gastrinoma]. / Métastases osseuses avec extension épidurale d'un gastrinome.

Malignant gastrinoma is a nonbeta islet cell tumor which rarely disseminates to the bone. However, in the case reported herein, diffuse metastatic bone disease with symptomatic epidural spread developed. Somatostatin and 99mTc-HDP bone scans demonstrated hot spots in the same sites, establishing that the bone lesions contained somatostatin receptor. Irradiation was effective in relieving pain.

[Osteoarthritis with rice bodies rich in calcium microcrystals. 4 cases with ultrastructural study]. / Arthropathies mécaniques avec grains de riz riches en microcristaux calciques. Quatre cas avec étude ultrastructurale.

Rice bodies are often found in inflammatory joint fluid specimens, especially from rheumatoid arthritis patients, but have rarely been reported in osteoarthritis. We found rice bodies in knee joint fluid specimens from four of 88 patients with osteoarthritis. There were three males and one female. Age ranged from 61 to 86 years. Three patients had slowly progressive knee osteoarthritis and one had rapidly destructive disease. Abundant, recurrent effusions occurred in all four patients despite one to five local corticosteroid injections per patient and radiation synovectomy in two patients. The joint fluid specimens contained 120 to 320 cells/mm3 and large numbers of rice bodies that stained with alizarin red S. Transmission electron microscopy studies showed that the rice bodies were composed of fibrin and contained numerous intra- and extra-cellular calcium crystals composed of apatite alone in two cases and of a combination of apatite and calcium pyrophosphate dihydrate in the two others. Collagen fibers and fragments of bone and cartilage were present in a few rice bodies. Phagocytic cells, type C synoviocytes, chondrocytes and a few inflammatory cells were also seen. These rice bodies composed mainly of fibrin and apatite may have played a role in the pathogenesis of the recurrent joint effusions in our patients.

[Importance of the HLA group in the diagnosis, prognosis and treatment of rheumatoid polyarthritis]. / Importance du groupe hla dans le diagnostic, le pronostic et le traitement de la polyarthrite rhumatoïde.

Determination of HLA typing in patients affected with rheumatologic diseases, is a major diagnosis tool. Beside the classic association HLA B27-ankylosing spondylitis, recent studies have demonstrated an anomaly high frequency of HLA-DW4 and HLA-DR4 in patients with rheumatoid polyarthritis as compared to a reference population. It has also been possible, in this disease, to determine HLA groups with a more severe rheumatoid arthritis and a higher risk of undesirable effects. However, these findings are, in practice, of limited interest, since the cost of such investigation does not justify looking for them systematically in order to establish a diagnosis, evaluate a prognosis or anticipate a therapeutic accident.